BIS and postoperative delirium

[bullard]

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I haven't routinely used a BIS for anything besides TIVA since finishing residency in 2010. Never seemed to change my management, especially not in the heart room where I spend a lot of time, and the studies have proven it doesn't prevent recall. Doesn't do much for speeding up recovery from general anesthesia either. Or so I thought.

Now Covidien or whoever owns BIS is selling it as a way to reduce the incidence of postoperative delirium. I heard about this through some of my CRNAs, as their CME seems to come strictly from drug and equipment companies. Anyway, I looked at some of the studies they cite and I'm not impressed. It seems to point in the direction of BIS reducing delirium but it doesn't seem like anything definitive. I haven't read through it all though.

What do y'all do? Are you finding that the BIS is helping you reduce postop delirium or at least speeding recovery?

 

[Murcielo]

They are probably piggy bagging to the recent article on EEG and the longer the time with burst supression the higher incidence of delirium. BIS is no EEG...But then again, if I were selling BIS I would still argue it could help decrease delirium, but professionally I use BIS like you, for TIVA when appropriate.

 

[Planktonmd]

This company is back to it's old habits of making up baseless claims and repeating them endlessly until people think they are facts!

 

[OB1🤙]

A bis is a monitor, not an intervention.

A monitor cannot change clinical outcomes.

 

[dhb]

This company is back to it's old habits of making up baseless claims and repeating them endlessly until people think they are facts!

They have a crappy product but they sure know how to market it!

 

[Impromptu]

I occasionally use it on very elderly patients. I don't routinely use it on TIVAs.

 

[WholeLottaGame7]

Probably referring to that Sieber study randomizing hip fx patients undergoing surgery under spinal + prop infusion to BIS of 4o or BIS of 80 that showed I think decreased duration of postop delirium (think incidence was unchanged).

Anyway, my take-home from that was more "don't do a GA plus a spinal for old people" than it was "use a BIS all the time."

I'm not anti-BIS (we used it a ton in residency), but I think it's utility is mostly in specific situations (TIVA, hx of intra-op awareness, etc). I don't think it's the worst thing in the world for residents to play around with it, especially when first starting out, because it can be interesting from an academic standpoint (how much or how little volatile certain patient populations need, for instance). But the more experienced you get, the less utility it has.

 

[dhb]

I'm not anti-BIS (we used it a ton in residency), but I think it's utility is mostly in specific situations (TIVA, hx of intra-op awareness, etc).

How can it be useful if it has been shown not to be reliable in preventing awareness?

 

[WholeLottaGame7]

How can it be useful if it has been shown not to be reliable in preventing awareness?

Makes the patient feel better when you tell them you're putting a special monitor on their forehead that monitors their brainwaves, yadda yadda yadda. I'm not above some placebo action every once in awhile.

 

[PainDrain]

If you ask me, sounds like the company decided they would try to pull the wool over the eyes of the CRNAs knowing their publications and research backgrounds are cr@p. Bis is a costly gimmick with scant data supporting its use.

 

[Velefunt]

Outside of residency, never used it again as it's unavailable to me. Previously used them in training on some TIVA's.

 

[Docuronium]

A bis is a monitor, not an intervention.

A monitor cannot change clinical outcomes.

How about a pulse ox?

 

[OB1🤙]

Look again at what I said.

 

[BLADEMDA]

J Neurosurg Anesthesiol. 2013 Jan;25(1):33-42. doi: 10.1097/ANA.0b013e3182712fba.
BIS-guided anesthesia decreases postoperative delirium and cognitive decline.
Chan MT1, Cheng BC, Lee TM, Gin T; CODA Trial Group.
Collaborators (16)

Author information

Abstract
BACKGROUND:
Previous clinical trials and animal experiments have suggested that long-lasting neurotoxicity of general anesthetics may lead to postoperative cognitive dysfunction (POCD). Brain function monitoring such as the bispectral index (BIS) facilitates anesthetic titration and has been shown to reduce anesthetic exposure. In a randomized controlled trial, we tested the effect of BIS monitoring on POCD in 921 elderly patients undergoing major noncardiac surgery.

METHODS:
Patients were randomly assigned to receive either BIS-guided anesthesia or routine care. The BIS group had anesthesia adjusted to maintain a BIS value between 40 and 60 during maintenance of anesthesia. Routine care group had BIS measured but not revealed to attending anesthesiologists. Anesthesia was adjusted according to traditional clinical signs and hemodynamic parameters. A neuropsychology battery of tests was administered before and at 1 week and 3 months after surgery. Results were compared with matched control patients who did not have surgery during the same period. Delirium was measured using the confusion assessment method criteria.

RESULTS:
The median (interquartile range) BIS values during the maintenance period of anesthesia were significantly lower in the control group, 36 (31 to 49), compared with the BIS-guided group, 53 (48 to 57), P<0.001. BIS-guided anesthesia reduced propofol delivery by 21% and that for volatile anesthetics by 30%. There were fewer patients with delirium in the BIS group compared with routine care (15.6% vs. 24.1%, P=0.01). Although cognitive performance was similar between groups at 1 week after surgery, patients in the BIS group had a lower rate of POCD at 3 months compared with routine care (10.2% vs. 14.7%; adjusted odds ratio 0.67; 95% confidence interval, 0.32-0.98; P=0.025).

CONCLUSIONS:
BIS-guided anesthesia reduced anesthetic exposure and decreased the risk of POCD at 3 months after surgery. For every 1000 elderly patients undergoing major surgery, anesthetic delivery titrated to a range of BIS between 40 and 60 would prevent 23 patients from POCD and 83 patients from delirium.

 

[BLADEMDA]

Br J Anaesth. 2013 Jun;110 Suppl 1:i98-105. doi: 10.1093/bja/aet055. Epub 2013 Mar 28.
Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction.
Radtke FM1, Franck M, Lendner J, Krüger S, Wernecke KD, Spies CD.
Author information

Abstract
BACKGROUND:
Postoperative delirium in elderly patients is a frequent complication and associated with poor outcome. The aim of this parallel group study was to determine whether monitoring depth of anaesthesia influences the incidence of postoperative delirium.

METHODS:
Patients who were planned for surgery in general anaesthesia expected to last at least 60 min and who were older than 60 yr were included between March 2009 and May 2010. A total of 1277 patients of a consecutive sample were randomized (n=638 open, n=639 blinded) and the data of 1155 patients were analysed (n=575 open, n=580 blinded). In one group, the anaesthesiologists were allowed to use the bispectral index (BIS) data to guide anaesthesia, while in the other group, BIS monitoring was blinded. Cognitive function was evaluated at baseline, 1 week, and 3 months after operation.

RESULTS:
Delirium incidence was lower in patients guided with BIS. Postoperative delirium was detected in 95 patients (16.7%) in the intervention group compared with 124 patients (21.4%) in the control group (P=0.036). In a multivariate analysis, the percentage of episodes of deep anaesthesia (BIS values <20) were independently predictive for postoperative delirium (P=0.006; odds ratio 1.027). BIS monitoring did not alter the incidence of postoperative cognitive dysfunction (7th day P=0.062; 90th day P=0.372).

CONCLUSIONS:
Intraoperative neuromonitoring is associated with a lower incidence of delirium, possibly by reducing extreme low BIS values. Therefore, in high-risk surgical patients, this may give the anaesthesiologist a possibility to influence one precipitating factor in the complex genesis of delirium. Clinical trial registration ISRCTN Register: 36437985. http://www.controlled-trials.com/ISRCTN36437985/.

 

[BLADEMDA]

Anesth Analg. 2014 May;118(5):977-80. doi: 10.1213/ANE.0000000000000157.
Sedation depth during spinal anesthesia and survival in elderly patients undergoing hip fracture repair.
Brown CH 4th1, Azman AS, Gottschalk A, Mears SC, Sieber FE.
Author information

Abstract
Low intraoperative Bispectral Index (BIS) values may be associated with increased mortality. In a previously reported trial to prevent delirium, we randomized patients undergoing hip fracture repair under spinal anesthesia to light (BIS >80) or deep (BIS approximately 50) sedation. We analyzed survival of patients in the original trial. Among all patients, mortality was equivalent across sedation groups. However, among patients with serious comorbidities (Charlson score >4), 1-year mortality was reduced in the light (22.2%) vs deep (43.6%) sedation group (hazard ratio

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, 0.43; 95% confidence interval, 0.19-0.97; P = 0.04) during spinal anesthesia. Similarly, among patients with Charlson score >6, 1-year mortality was reduced in the light (28.6%) vs deep (52.6%) sedation group (HR 0.33; 95% confidence interval, 0.12-0.94; P = 0.04) during spinal anesthesia. Further research on reduced mortality after light sedation during spinal anesthesia is needed.

 

[BLADEMDA]

Anesth Analg. 2015 Sep 28. [Epub ahead of print]
Intraoperative Electroencephalogram Suppression Predicts Postoperative Delirium.
Fritz BA1, Kalarickal PL, Maybrier HR, Muench MR, Dearth D, Chen Y, Escallier KE, Ben Abdallah A, Lin N, Avidan MS.
Author information

Abstract
BACKGROUND:
Postoperative delirium is a common complication associated with increased morbidity and mortality, longer hospital stays, and greater health care expenditures. Intraoperative electroencephalogram (EEG) slowing has been associated previously with postoperative delirium, but the relationship between intraoperative EEG suppression and postoperative delirium has not been investigated.

METHODS:
In this observational cohort study, 727 adult patients who received general anesthesia with planned intensive care unit admission were included. Duration of intraoperative EEG suppression was recorded from a frontalEEG channel (FP1 to F7). Delirium was assessed twice daily on postoperative days 1 through 5 with the Confusion Assessment Method for the intensive care unit. Thirty days after surgery, quality of life, functional independence, and cognitive ability were measured using the Veterans RAND 12-item survey, the Barthel index, and the PROMIS Applied Cognition-Abilities-Short Form 4a survey.

RESULTS:
Postoperative delirium was observed in 162 (26%) of 619 patients assessed. When we compared patients with no EEG suppression with those divided into quartiles based on duration of EEG suppression, patients with more suppression were more likely to experience delirium (χ(4) = 25, P < 0.0001). This effect remained significant after we adjusted for potential confounders (odds ratio for log(EEG suppression) 1.22 [99% confidence interval, 1.06-1.40, P = 0.0002] per 1-minute increase in suppression). EEG suppression may have been associated with reduced functional independence (Spearman partial correlation coefficient -0.15, P = 0.02) but not with changes in quality of life or cognitive ability. Predictors of EEG suppression included greater end-tidal volatile anesthetic concentration and lower intraoperative opioid dose.

CONCLUSIONS:
EEG suppression is an independent risk factor for postoperative delirium. Future studies should investigate whether anesthesia titration to minimize EEG suppression decreases the incidence of postoperativedelirium. This is a substudy of the Systematic Assessment and Targeted Improvement of Services Following Yearlong Surgical Outcomes Surveys (SATISFY-SOS) surgical outcomes registry (NCT02032030).

 

[BLADEMDA]

BMC Anesthesiol. 2015 Apr 28;15:61. doi: 10.1186/s12871-015-0051-7.
Intraoperative burst suppression is associated with postoperative delirium following cardiac surgery: a prospective, observational study.
Soehle M1, Dittmann A2, Ellerkmann RK3, Baumgarten G4, Putensen C5, Guenther U6.
Author information

Abstract
BACKGROUND:
Postoperative delirium (POD) occurs frequently after cardiac surgery and is associated with increased morbidity and mortality. We analysed whether perioperative bilateral BIS monitoring may detect abnormalities before the onset of POD in cardiac surgery patients.

METHODS:
In a prospective observational study, 81 patients undergoing cardiac surgery were included. Bilateral Bispectral Index (BIS)-monitoring was applied during the pre-, intra- and postoperative period, and BIS, EEGAsymmetry (ASYM), and Burst Suppression Ratio (BSR) were recorded. POD was diagnosed according to the Confusion Assessment Method for the Intensive Care Unit, and patients were divided into a delirium and non-delirium group.

RESULTS:
POD was detected in 26 patients (32%). A trend towards a lower ASYM was observed in the delirium group as compared to the non-delirium group on the preoperative day (ASYM = 48.2 ± 3.6% versus 50.0 ± 4.7%, mean ± sd, p = 0.087) as well as before induction of anaesthesia, with oral midazolam anxiolysis (median ASYM = 49.5%, IQR [47.4;51.5] versus 50.6%, IQR [49.1;54.2], p = 0.081). Delirious patients remained significantly (p = 0.018) longer in a burst suppression state intraoperatively (107 minutes, IQR [47;170] versus 44 minutes, IQR [11;120]) than non-delirious patients. Receiver operating analysis revealed burst suppression duration (area under the curve = 0.73, p = 0.001) and BSR (AUC = 0.68, p = 0.009) as predictors of POD.

CONCLUSIONS:
Intraoperative assessment of BSR may identify patients at risk of POD and should be investigated in further studies. So far it remains unknown whether there is a causal relationship or rather an association between intraoperative burst suppression and the development of POD.

 

[Scotty_G]

Bis me outta here !

 

[Wiscoblue]

I don't use the BIS, but from looking at these studies, would you guys suggest that it should be a standard monitor in the elderly?


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[deleted162650]

Or you could just dial back the gas. In the geezer crowd I like to make them prove to me I'm not giving enough anesthetic. It's amazing how little volatile most of this population requires.

 

[nap$ter]

I occasionally use it on very elderly patients. I don't routinely use it on TIVAs.

i occasionally use it to hide my coffee behind, but it's not even very good for that...

 

[nap$ter]

I don't use the BIS, but from looking at these studies, would you guys suggest that it should be a standard monitor in the elderly?


Sent from my iPad using Tapatalk

no.